Medicaid Incentives for Prevention of Chronic Diseases Evaluation (CMS-10477)

Forms and Documents

Document Name	Status
Form CMS-10477 Administrative Cost Forms for MIPCD Form and Instruction	New
Form CMS-10477 Beneficiary Satisfaction Survey Form and Instruction	Unchanged
Form CMS-10477 Focus Groups Form and Instruction	Unchanged
Form CMS-10477 Stakeholder Interview Form and Instruction	Unchanged
Form CMS-10477 Site Visit Interviews Form and Instruction	Unchanged
MIPCDSupportStatementPartB.pdf Supporting Statement B	2014-10-01
Attachment_6e_Reminder_Letter.pdf Supplementary Document	2013-08-07
Attachment_6b_Survey_Cover_Letter.pdf Supplementary Document	2013-08-07
Attachment_6a_Prenotification_Letter.pdf Supplementary Document	2013-08-07
Attachment_4c_Recruitment_Flyer_Template.pdf Supplementary Document	2013-08-07
Attachment_4f_Reminder_Email.pdf Supplementary Document	2013-08-07
Attachment_2b_Physician_Background_FAQ (revised).pdf Supplementary Document	2013-08-07
Attachment_2a_Physician_Interview_Email_Invitation.pdf Supplementary Document	2013-08-07
Attachment_5b_Interview_Email_Invitation.pdf Supplementary Document	2013-08-06
Attachment_5a_Background_FAQ.pdf Supplementary Document	2013-08-06
MIPCD_Supp_State_Part_A_06_25_2014.docx Supporting Statement A	2014-10-01

IC Document Collections

IC ID	Document Title	Status
213346	Administrative Cost Forms for MIPCD Form and Instruction	New
208113	Beneficiary Satisfaction Survey Form and Instruction	Unchanged
208112	Focus Groups Form and Instruction	Unchanged
208111	Stakeholder Interview Form and Instruction	Unchanged
208110	Site Visit Interviews Form and Instruction	Unchanged

ICR Details

OMB Control No: 0938-1219	ICR Reference No: 201410-0938-001
Status: Historical Active	Previous ICR Reference No: 201308-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: 20261
Title: Medicaid Incentives for Prevention of Chronic Diseases Evaluation (CMS-10477)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/29/2014
	Date Received in OIRA: 10/01/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2017	36 Months From Approved	01/31/2017
Responses	4,706	0	4,686
Time Burden (Hours)	2,236	0	1,836
Cost Burden (Dollars)	0	0	0

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Abstract: Section 4108 (a) (1) of the 2010 Affordable Care Act (ACA) established the Medicaid Incentive for Prevention of Chronic Disease program (MIPCD). This national demonstration awarded 10 grants to states to implement programs that provide incentives to Medicaid beneficiaries of all ages who participate in prevention programs and demonstrate changes in health risk and outcomes, including the adoption of healthy behaviors. Programs address at least one of the following prevention goals: tobacco cessation, controlling or reducing weight, lowering cholesterol, lowering blood pressure, and avoiding the onset of diabetes or in the case of a diabetic, improving the management of the condition. Programs are comprehensive, widely available, easily accessible, and based on relevant evidence-based research and resources. Under Section 4108 (d) of the Affordable Care Act, Health and Human Services Secretary through the Centers for Medicare and Medicaid Services (CMS) awarded a contract to Research Triangle Institute to conduct an independent assessment of these 10 State demonstration Grantees. This assessment will focus on evaluating:(A)the effect of the initiatives on the use of health care services by Medicaid beneficiaries participating in the program;(B)the extent to which special populations (adults with disabilities, adults with chronic illnesses, and children with special health care needs) are able to participate in the program; (C)the level of satisfaction of Medicaid beneficiaries with respect to the accessibility and quality of health care services provided through the program; and(D)the administrative costs incurred by State agencies that are responsible for administration of the program. To address these topics we will be conducting Site Visits, Stakeholder Interviews, Focus Groups, Beneficiary Survey and Administrative Cost Forms.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 4108 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 4108 Name of Law: Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 42018	07/18/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 57932	09/26/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Site Visit Interviews	CMS-10477, CMS-10477, CMS-10477, CMS-10477, CMS-10477	Management staff interview protocol and consent ,   Recruitment staff interview protocol and consent ,   Staff educator interview protocol and consent ,   State evaluator interview protocol and consent ,   Clinic staff interview protocol and consent
Beneficiary Satisfaction Survey	CMS-10477, CMS-10477, CMS-10477, CMS-10477	Beneficiary survey questionnaire ,   Beneficiary survey phone follow-up for non-responders ,   CATI_Script_Spanish_new_clean ,   Survey_Spanish_new_clean
Administrative Cost Forms for MIPCD	CMS-10477, CMS-10477	Combined Administrative Cost Form - Informed Consent ,   Yearly Admin Cost Form
Stakeholder Interview	CMS-10477, CMS-10477, CMS-10477, CMS-10477	Stakeholder interview appointment reminder ,   Physician interview verbal consent script ,   Stakeholder interview guide and consent form ,   Stakeholder interview scheduling script
Focus Groups	CMS-10477, CMS-10477, CMS-10477, CMS-10477, CMS-10477, CMS-10477, CMS-10477	Screener for focus group eligibility ,   Discussion guide for focus groups ,   Participant contact release form for focus groups ,   Focus group consent form ,   Screener_Spanish_new_clean ,   Participant_Contact_Release_Forms_Spanish_new_clean ,   Consent_Forms_Spanish_new_clean

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	4,706	4,686	0	20	0	0
Annual Time Burden (Hours)	2,236	1,836	0	400	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The addition of the two Administrative Costs Forms adds two new collection instruments to this package. These forms increase the burden to include 20 more respondents; 400 more total burden hours. The new total burden associated with this information collection is 2,236 hours.

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Annual Cost to Federal Government: $155,126

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/01/2014

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